Professional Documents
Culture Documents
F To be attached to the Application Form for the 6-month UNEP/UNESCO/BMU International Postgraduate Course on
Environmental Management for Developing and Emerging Countries at Technische Universität Dresden, FRG E
2. Family History
What relatives or associates of the examinee have had tuberculosis?.......................….............….….........
What relatives or associates have had diabetes? ...........................................................................…….......
Have any relatives had nervous or mental disorders? .............................................................…..…............
3. Personal History
Has the examinee suffered from any of the following diseases? If so when?
Yes No When
Tuberculosis q q ................…..….......…......
Cardiac diseases q q ............................…….......
Gastrointestinal disabilities q q .......................…..……......
Arthritis q q ...........................……........
Genito-urinary or renal diseases q q .............................……......
Malaria q q ............................…….......
Diabetes q q ............................…….......
Acute or chronic respiratory diseases q q ...............................….…...
Has the examinee had typhoid fever? q q ....................…..…...…......
or anti-typhoid inoculation? (When?) q q .........................……..........
Polio q q .............................……......
Tetanus q q ...............................……....
or anti-tetanus inoculation? (When?) q q ...............................……....
Intestinal parasites q q ...........................……........
When was the examinee last successfully vaccinated against smallpox? .....................................
Any diseases or injury not noted above?
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F Please, type or use block capitals! E
4. Physical Examination
- Albumen ..........................................................................................….............
- Sugar .......................................................................................……….........
- Cells .......................................................................................……...…......
- Haemoglobin .............................................................................................………………...
(13) Does the examination reveal any facts not enumerated above affecting or likely to affect the health of the
examinee?
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Address: ........................................................................................…………....
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Telephone : .................................................................…....…………
Fax: ..............................................................................………….……
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Date Signature
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Seal